Glottic Insufficiency: Vocal Fold Paralysis, Paresis, and Atrophy

Abstract

■ Glottic insufficiency is one of the most common contributing factors in patients who present with dysphonia and one of the easiest findings to overlook in the clinical evaluation.

■ The most common causes of symptomatic glottic insufficiency are unilateral vocal fold paralysis, unilateral or bilateral vocal fold paresis, and presbylaryngis.

■ Treatment of “early” unilateral vocal fold paralysis is individualized for each patient, and takes into account the patient’s risk of aspiration, vocal demands, nature of neural injury, and LEMG findings.

■ Videostroboscopy plays a pivotal role in the evaluation of suspected vocal fold paresis. Subtle clues include:

- Mild bowing of the vocal fold(s)

- Incomplete glottic closure

- Prolonged “open phase” of vibratory cycle (see Chap. 2, “Principles of Clinical Evaluation for Voice Disorders”)

- Increased vibratory amplitude in the paretic vocal fold

- Chasing/asynchronous mucosal wave propagation

■ Loss of vocal projection and voice fatigue with extended use are classic symptoms of vocal fold paresis and can easily be missed in the history.

■ All unexplained vocal fold paralysis should be investigated with imaging studies (CT or MRI), tracing the entire RLN from skull base to upper chest.

■ Parkinson’s Disease (PD) often presents with dysphonia and vocal fold bowing and can be confused with presbylaryngis. The clinical distinction is important, as PD patients are generally poor surgical candidates, and should instead undergo voice therapy as primary treatment for their dysphonia.